MENTALLY ILL PEOPLE IN SAN FRANCISCO ARE CYCLING IN AND OUT OF EMERGENCY ROOMS by Heather Knight

Three people have forwarded this article to me. Heather Knight is a journalist who often writes about mental illness.

MENTALLY ILL PEOPLE IN SAN FRANCISCO ARE CYCLING IN AND OUT OF EMERGENCY GOOMS. ONE DOCTOR SHARES STORIES ABOUT OUR BROKEN SYSTEM.

Mentally ill people in S.F. are cycling in and out of emergency rooms. One doctor shares stories about our broken system

Dr. Scott Tcheng will never forget some of the people who come to his San Francisco emergency room in desperate need of help.

One man who arrived by ambulance looked like the Joker, his face and hands covered in animal blood. A 911 caller had spotted him eating a raccoon crushed by a car on a city street.

Tcheng has treated patients high on methamphetamines who are convinced a mouse is crawling inside their body or that someone has cut off their genitals with a sword.

One person on meth was treated after trying to steal a parked ambulance — with a patient inside. Another tried to captain the Pampanito, the floating submarine museum at Fisherman’s Wharf, but fell into the bay. He had hypothermia by the time a rescue team fished him out.

Just the other day, Tcheng treated a 31-year-old woman who is homeless, suffers from schizophrenia and has come to the ER about 150 times — usually to request pregnancy tests, but sometimes just for food and a place to sleep. This time, the pregnancy test came back positive, but the woman refused offers of hotel vouchers or a shelter bed. So the hospital released her back to the streets.

Other patients suffering from severe, untreated mental illness or meth-fueled psychosis have become violent toward hospital staffers, wrecked medical equipment, brandished knives and hurled their own feces. Some return to the ER shockingly often. Tcheng said one of his patients has visited emergency rooms around San Francisco hundreds of times in the past year.

What unites these patients, beyond their struggles, is their clear need for long-term care. But they’re usually not getting it. Not even in a rich city and a rich state that claim to be compassionate and caring.

The patients are often too sick to accept care. And frequently, there isn’t enough care, or adequate services, to meet their needs. Tcheng must send them back into the world, untethered, until the next ER visit.

“It’s so important that the people of San Francisco know about this,” Tcheng said, explaining his decision to go public about his patients. “They walk by it every day on Market Street and in SoMa, but the average San Franciscan doesn’t realize how deep it goes.”

Tcheng said he’s “cautiously optimistic” that a sweeping new proposal from Gov. Gavin Newsom could make a difference.

Called CARE Court, Newsom’s plan would require every county to provide needed treatment for people suffering from psychosis, whether due to mental illness or drug addiction, and would mandate that patients accept the help. Patients could be brought to the civil court because they allegedly committed a crime, because their involuntary psychiatric hold is ending or because they’re deteriorating on the streets.

If they don’t comply with a court-ordered treatment plan, a judge could turn them over to the regular criminal system, order additional involuntary holds or move toward conservatorship.

Newsom’s proposal suggests he has learned lessons since his time as mayor, when he dealt with recession-fueled budget cuts in part by slashing the number of psychiatric beds at San Francisco General Hospital. A dire bed shortage remains all these years later. He also cut beds in homeless shelters and closed drop-in centers where people could get help during the day.

San Francisco General Hospital is now the only hospital in the city with a dedicated psychiatric emergency room, but there are far more people needing its services than there are beds. So they’re often taken to regular emergency rooms for stabilization or because they also have medical issues that need to be addressed.

That sometimes means other patients — with strokes, heart attacks or injuries — must wait, Tcheng said.

“Someone coming in three and four times a day takes a toll on the system,” he said. “It’s incredibly dispiriting.”

He compared the fight against San Francisco’s threefold crisis — a lack of housing, mental health care and drug treatment — to building a three-legged stool. Addressing just one or two legs won’t work.

Tcheng, a 36-year-old Potrero Hill resident, works in four emergency rooms around the city, but couldn’t get permission from his bosses to name them. But really, they’re interchangeable — each one flooded daily with unsheltered patients suffering from psychosis who need treatment but aren’t getting it.

Rachel Rodriguez, a social worker in another emergency room in the city, confirmed the crisis exists at her hospital, too. She couldn’t talk for a while Tuesday because, as she texted, her ER was “bursting” with psychiatric patients. She said social workers are so strapped caring for psychiatric patients that they often can’t provide help to others who need it — such as domestic violence victims or those hurt in car crashes.

She has started emailing the Department of Public Health every day with a tally of the people waiting for acute psychiatric beds in her hospital alone. One email from last month showed 15 patients ranging in age from 21 to 86, a few waiting a month or longer.

Rodriguez said she’s reserving judgment about Newsom’s plan. But her husband, Charlie Berman, a clinical social worker in San Francisco, said he fears it’s nothing more than “a political facade masking the ineffectuality of a rotten system,” and called the city’s emergency rooms “extensions of the Tenderloin with ambulances providing taxi service in between.”

Berman said the governor’s plan will fail without a major investment in locked psychiatric wards and beds designed for people with both mental illness and substance use disorder. Both are very expensive.

Tcheng is more hopeful — provided the governor finds the money to pay for treatment through CARE Court. Civil libertarians are already speaking out against the plan, saying that mandating care is inhumane and not as effective as providing voluntary services, but Tcheng said the real inhumanity is playing out in the city’s emergency rooms every day.

“I fundamentally reject the notion it’s more compassionate to let these people live on the streets and die in alleyways than to mandate that they get care,” Tcheng said. “I just think it’s appalling what San Francisco has allowed to happen to some of these patients.”

He cited Mary Botts, the San Francisco homeless woman dubbed “Princess Leia” for often wearing her hair in buns on the sides of her head, sometimes held together with syringes. She frequently walked into traffic at Castro and Market streets and slept in the gutter.

Tcheng said he treated her at least a dozen times — but kept releasing her back to the streets because she didn’t want help and there was nowhere to send her. She died of a drug overdose in November 2020 at age 28.

At a Board of Supervisors hearing last week, Superior Court Judge Michael Begert addressed the severe shortage of treatment beds. He oversees drug court, which aims to clear defendants’ arrests if they can prove they’ve successfully addressed the drug problem that led them to commit the crime. Begert said he has never been able to access a treatment bed for somebody who allegedly committed a crime and suffers from both mental illness and a drug addiction. Instead, such people often linger in jail — with one person waiting 264 days behind bars for a bed — until they’re eventually released, having further deteriorated while jailed.

“This is not treatment on demand, and they’ve been talking about treatment on demand for at least 25 years,” Begert said.

Two years ago, the Department of Public Health released a study stating the city needs 400 more treatment beds, but it’s added only 89 beds since then. And even 400 might not be enough, said Supervisor Hillary Ronen. She said the board hearing left her with “a mix of exasperation, sadness, frustration, but also a new resolve” to vastly improve the city’s mental health system.

Ronen said she doesn’t know enough about CARE Court to form an opinion, but hopes it’s not another “shiny new program” from a politician wanting to look good.

For now, Tcheng will keep seeing the same patients in his ER, and many will leave no better off than when they arrived. The man who tried to steal the submarine got released after he slept off his high. Tcheng doesn’t know what happened to him after that.

As for the man who ate a raccoon?

Tcheng said he asked a psychiatrist to evaluate whether he should be treated under an involuntary hold. But, he said, the man wasn’t deemed to fit the requirement of being “gravely disabled” under state law if he could secure his own food. Even if that food was roadkill.

Tcheng said he managed to get a different doctor to test the man for rabies, but he lost track of him after that.

“Hopefully, he got some sort of psychiatric care,” Tcheng said. “But knowing San Francisco, I doubt it.”

San Francisco Chronicle columnist Heather Knight appears Sundays and Wednesdays. Email: hknight@sfchronicle.com Twitter: @hknightsf

Dr. Scott Tcheng is an emergency room physician at several San Francisco hospitals.

Photo: Carlos Avila Gonzalez/The Chronicle

From the oldest

NEED A PORCH OR PATIO IN MIDTOWN SACRAMENTO CA by Marcy Murphy

Urgent S.O.S.
Need a Safe Place to Rest at Night for Woman with Service Dog.

A porch or patio would be fine, with coverage from wind, rain, and cold and dimly lit for safety if possible. I am in my 50's, have a housing voucher, spend every day searching for safe and affordable housing, do not party and am extremely clean and respectful, do not have visitors where I sleep and come with built-in security for your property with my PTSD service dog. I am self-sufficient, do not litter, and do not panhandle. I just need a safe, dry place to rest and recharge every night.

It's already extremely cold and dangerous, with winter approaching and I cannot afford for myself or my service dog to risk getting sick and throwing us off track.

Please text or call me at 916-500-8360 if you can help, if even for a short time.

Forever grateful. . . . . . . .

Tiny homes…

Tiny homes…

This is what our community should be demanding of our leaders in our fight to end homelessness. Spending millions more on shelters is a waste of money, a waste of time, and a waste of resources.

There is only one cure to homelessness, and that is a "Home.”

Shelters are merely a way of keeping the money flowing back through dangerous hands. They are unwanted, untrusted, unsuccessful smokescreens that make numbers look good for a minute, at best. To the homeless, they are viewed as concentration camps meant only to round us up like cattle going to slaughter.

Would you want to move in with a group of people who have been living in filth and feces, infected with God knows what because they have not been provided clean water, bathing facilities, restrooms and basic medical care for years? Would you feel safe at night closing your eyes amongst a group of people with untreated mental health issues, self-medicating as a means of surviving conditions and treatment not fit for a dog? Would you feel safe?

Come on Sacramento, please have a heart and save the righteous judgment.

Who cares why a person is homeless? He still deserves the dignity of a second chance. Who cares who is on drugs? He still deserves a real opportunity for recovery. Who cares who is crazy? He still deserves the MHSA funding to help him recover and live amongst his peers.

Most importantly, you cannot know who a person is while they are fighting for their life every second of every day. You cannot judge their mental health under dire circumstances. Trust me, under the same conditions, you may not look so attractive either.

JUST SAY "NO" TO SHELTERS
AND "YES" TO TINY HOMES!

OUR COUNTRY'S SHAME by Dede Ranahan

My friend, Travis Christian, also known as state prisoner BB8099, is in trouble. Big trouble. I visited with him Sunday at Folsom State Prison in Sacramento, California. He’s in isolation not-so-fondly referred to as the hole. Or solitary confinement. He’s been there about two weeks.

Travis is 33. He has serious mental illness — bipolar disorder or schizoaffective disorder or some other disorder. Who knows? We try to label these illnesses and put people’s brains in neat little boxes. Everyone’s brain is different. Brains don’t fit in neat little boxes.

Travis has served eight years of a ten-year prison sentence. In a psychotic fury he stabbed someone he thought was Satan and ended up incarcerated. Never mind his serious mental illness. Law enforcement says he committed a crime.

While with a prison psych tech, Travis experienced another psychotic episode. He thought the tech was Satan. He punched him. Travis was sent to the hole for months — at first, no radio, no TV, no paper, no pencils, no books, nothing. Travis was allowed four walls and his sick mind.

Earlier this year, I began visiting Travis once a month. The last time I saw him was our best visit. It felt like we were becoming friends who could give and take and talk honestly with each other. Travis looked good — short cut hair, a small beard, bright eyes. He was taking a college health class. He was writing songs and singing them in his prison church. He was counting the dwindling days of his sentence. Only two or so more years. He would move home and work with his mom in her thrift store. He would get a dog. And a girlfriend. He’d be a free man.

A couple months ago, I received a different kind of letter from Travis. He wrote, “I’m doing great. I’m worried about you driving from Lincoln to Folsom to see me. What if you get in a car accident? We’re good, Dede. You don’t have to come visit me anymore.”

I wasn’t sure how to interpret Travis’s letter. Had I offended him? I didn’t know but I wrote back that I would follow his lead. I assured him, “I don’t visit you because I think you need me or because I’m trying to ‘fix’ you. I visit you because I hope to give you a break from your prison routine once a month. And I like talking with you. I like you, Travis.” The next letter from Travis was upbeat again. Lots of positive thoughts and good wishes for me. No mention of more visits.

Last Friday, I received a text message from Travis’s mom, Kathy. “Dede, Travis is in isolation again. Things have been bad. He decided he didn’t need his meds anymore. I begged the prison staff not to take him off his meds. We’ve been down this road before and it always ends badly. The staff said they would monitor him. While they were ‘monitoring’ him, he tried to kill himself by breaking his neck. He was put in a crisis bed for a few days and then released to a new cell with a new cellmate. Something happened. They might be charging him with attempted murder. They say I have to visit Travis to find out what happened. I can't go this weekend. Can you go see him?”

Yesterday, the prison shuttle bus dropped me off at a different building, Block A. I had a 10:30 AM appointment to visit with Travis for an hour and a half. In the visiting area, nine booths lined up with a chair and a phone in front of each prisoner’s box. We would talk to each other over the phone with glass separating us. No hugs. No pats on the back this time. Travis entered the visiting box with his wrists in chains connected to a chain around his waist. He waited for the guard to remove them. He didn’t know I was coming. I tried to smile. I asked, “What happened?”

Travis was on new meds when he was put into the new cell with the new cellie. It takes a while for meds, even if they’re the right meds, to kick in and help organize a disorganized brain. At first, things were okay. But then the cellie said something that set Travis’s mind whirling. He said something about “demons.” Travis said, “I argued with myself for a day. My mind said, ‘Your cellie is Satan.’ I said, ‘No, he’s not Satan.’ My mind said, ‘Yes, he is Satan.’” History repeatng itself.

Travis decided he had to rid his cellie of Satan. He tried to choke him. Three guards fought with Travis to get him to release his hold on his cellie’s neck. They beat him with a club. They broke his shoulder. Travis’s psychosis was strong. It made Travis strong.

Now Travis is in solitary again. An old pattern surfaces — Satan, fear, outbursts, trouble, punishment. Travis doesn’t know how long he’ll be in the hole this time. He doesn’t know what charges he’ll face. The guards brought him a radio a couple days ago. He listens to music. He reads a book. Another prisoner gave him some coffee to brew in his cell. He gets to be outside in the yard — in a 10 X 15 foot cage — for a few hours each week. He’s grateful.

“I’m fine, Dede. I’m fine. I have to learn from this. I have to be an adult and take responsibility for my actions. I used soap to paste photos on my cell wall. I put up photos of myself when I was a little boy. I look at that little boy in the photos. He never thought he’d be in prison. I have to take care of that little boy. I have to take care of me. My mom’s love makes me want to take care of me.”

Travis hasn’t been able to talk to his mom since he got in trouble. He says, “Tell her I love her. Ask her to please send some stamps and envelopes so I can write to her. And some books. I need some uplifting stories to read.”

Kathy and Travis’s sister will visit Travis next weekend. They’ll drive up from Southern California. Kathy says, “I love my son, Dede. I visit him. I put money in the commissary for him so he can buy what he needs. I send him packages. Otherwise, I don’t know how to help him. He’s difficult to treat because he always tries to put on a good face. To seem fine. Prisons like to make money. They make money off my phone calls to Travis. They make money from the visitor vending machines. They make money based on the size of the inmate population. Sometimes, I think they try to keep prisoners locked up to add to their bottom line.”

Shortly before noon I told Travis, “I’ll come visit you again. Like before.”

“Thank you,” he said. “I love you, Dede.”

I waited for the shuttle bus to take me back to the main entrance. I asked a roaming guard, “What percentage of this prison’s inmates do you think have a mental illness?” He said, “A lot. Probably 50 percent.” I told him what had happened to Travis. “Why would they put him back in a cell with another prisoner while they’re still adjusting his meds?” The guard said, “A panel makes the decision about where to house a prisoner. I don’t know if they know what they're doing when it comes to mental illness.”

This guard, probably in his forties, seemed empathetic. He seemed weary. He and I agreed that mental illness is such a huge problem and it impacts so many areas — homelessness, crime, drug and alcohol addiction, suicide — that no one seems to know how to solve it. Appropriate, accessible mental illness care and the decriminalization of mental illness would be a good place to start.

“Don’t stress too much,” the guard said. “Three years ago I had a stroke brought on by stress. Take care of yourself.”

“I try,” I said, “but it’s hard to walk away from all the horrendous suffering going on. I’ve been a mental illness advocate for over twenty-five years. Nothing’s getting better. Everything’s getting worse. This is our country’s shame.”

The shuttle bus arrived. I got on. Travis went back to the hole.

Travis

Travis

PLEASE GIVE YOUR LEGISLATORS A COPY OF MY BOOK, BREAKDOWN by Lynn Nanos

While I was working as a social worker on an inpatient psychiatric unit, I became disillusioned and shocked at the extremely high rate of readmissions by patients. Even though the typical length of stay lasted less than a week, it seemed as though I was caring for the patients on a long-term basis. Whenever they returned, we picked up where we had left off since they were last discharged. 

I learned if they followed through with the previous recommendations made by the psychiatrist, nurse, and myself. The recommendations included taking their prescribed medications, attending structured therapeutic groups, attending appointments with their psychotherapists, psychiatrists, nurse practitioners, and rehabilitative outreach workers. Sometimes they were expected to access government benefits, such as food and shelter, by completing applications.

I often encouraged patients to use their state-funded Department of Mental Health (DMH) rehabilitative outreach workers as much as possible. These workers were expected to help their clients access housing (e.g., 24-hour supervised group residential programs), vocational services, transportation, and outpatient treatment providers. And I listed these services whenever I recommended DMH and offered applications to patients. 

As I revisited the patients revolving through the door of our broken system in mobile emergency services, I caught a glimpse of how seriously mentally ill patients on inpatient might be worse off than when I was working there. Recently, a social worker and friend who works on inpatient psychiatry expressed her belief that DMH should be doing a lot more to resolve homelessness. I agree with her. Her patients tell her that their DMH case managers tell them, “We don’t help with housing.”

Really? Disillusionment sets in again. If they don’t help with housing, then what does DMH help with? Without supportive and supervised housing, seriously mentally ill people will inevitably have difficulty taking care of themselves, leading to further hospitalizations. Instructing your clients to go elsewhere for help with housing is not acceptable. DMH is supposed to care for and protect the most severely ill. Yet, they’ve fallen short. 

I wrote the book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, to expose the injustices that I’ve seen in the field. Breakdown closely exposes barriers to patients getting the help that they need. The shortage of inpatient beds, increased rates of criminalization, overly restrictive involuntary hold criteria, premature inpatient discharges, and insufficient means to ensure that patients adhere to their outpatient treatment plans make for a broken system. Consequently, too many patients end up homeless, jailed, harming themselves, harming others, or even dead.

My book educates the public about the plight of those who need the most help. Increased awareness of a problem tends to inspire change. My greatest hope is that my book motivates people to advocate for legislative improvements of the system. Please tell your legislators about Breakdown and give it to them. 

Click on link below to access Lynn’s book on Amazon:
Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry

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